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National Center for Primary Care Morehouse School of Medicine . The Integration of Behavioral Health and Primary Care. George Rust, MD, MPH, FAAFP, FACPM Father of Dan & Christina, Husband of Cindy, Professor of Family Medicine and Director, National Center for Primary Care .

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the integration of behavioral health and primary care
National Center for Primary Care

Morehouse School of Medicine

The Integration of Behavioral Health and Primary Care

George Rust, MD, MPH, FAAFP, FACPMFather of Dan & Christina, Husband of Cindy,Professor of Family Medicine and Director, National Center for Primary Care

national center for primary care at morehouse school of medicine
National Center for Primary Care at Morehouse School of Medicine

Promoting Excellence in Community-Oriented Primary Health Care and Optimal Health Outcomes for all Americans

what is primary care
What Is Primary Care?
  • CFirst Contact Care
  • CComprehensive
  • CContinuous
  • CCoordinated
  • CContext of Family & Community
what is primary care1
What Is Primary Care?
  • Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

Institute of Medicine, 1996

primary care is relational care
Primary Care is Relational Care

Personalismo y ConfianzaTrump Evidence-Based Medical Advice

behavioral health physical health
Behavioral Health Physical Health
  • “Baseball is 90% mental -- the other half is physical."

-- Yogi Berra

partnerships on behavioral health in primary care
Partnerships on Behavioral Health in Primary Care

Federal Partners Senior Workgroup

Satcher Health Leadership Institute

Carter Center

National Center for Primary Care

Rollins School of Public Health

Southeast Regional Clinicians’ Network

who global burden of disease
WHO Global Burden of Disease

All Behavioral Health -- Mental Illness, Suicide, Alcohol, & Drug Use = 21.6%

Murray CJL, Lopez AD, eds. The global burden of disease and injury series, volume 1: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: World Health Organization and the World Bank, Harvard University Press, 1996.

depression in primary care
Depression in Primary Care
  • Survey of 1898 patients in 88 primary care practices
  • Patients meeting DSM criteria for depression w/in past 30 days
      • 21.7% of women
      • 12.7% of men

Rowe MG. Correlates of Depression in Primary Care. Journal of Family Practice, 1995.

Why Primary Care?

18% Prevalence of Alcohol Abuse or Dependence in Primary Care

McQuade et al; Detecting symptoms of alcohol abuse in primary care. Archives of Family Medicine, 2000.

screening vs readiness to change
Screening vs. Readiness to Change
  • 7 VA Clinics --36% screened positive for alcohol misuse

Readiness to Change in Primary Care Patients Who Screened Positive for Alcohol MisuseWilliams et al. Ann Fam Med 2006;4:213-220.

is primary care failing
Is Primary Care Failing?
  • “About 70 percent of the population sees one of the 255,173 primary care physicians at least once every two years.”


  • “94 percent of primary care physicians failed to include substance abuse among the five diagnoses they offered when presented with early symptoms of alcohol abuse in an adult patient.”
  • “Most patients (53.7 percent) said their primary care physician did nothing about their substance abuse:
    • 43 percent said their physician never diagnosed it
    • 10.7 percent believe their physician knew about their addiction and did nothing about it.”

Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. CASA- National Center on Addiction & Substance Abuse at Columbia University, April 2000.

usual care sub optimal care
Usual Care = Sub-Optimal Care
  • Fail to screen / detect
  • Fail to diagnose
  • Fail to treat
  • Fail to treat adequately
  • Fail to treat to remission
typical primary care patient
“Typical” Primary Care Patient
  • A1C (Diabetes)
  • BP (Hypertension)
  • Cholesterol /LDL
  • Depression
  • Plus – Osteoarthritis / Pain Mgt (Self-medicating with sister’s Vicodin)
  • Plus – Social ComplexitiesHusband unemployed, now drinking heavily; teens caught up in juvenile justice system.


co morbidities abound
Co-morbidities Abound!
  • He’s just one patient, how bad could it be???
  • Diabetes
  • Arthritis
  • COPD
  • CHF
  • Stroke
  • Pneumonia
  • Cancer
  • Depression
  • Alcohol / substance abuse

* 21 ER Visits * 139 hospital bed-days

complex co morbidities
Complex Co-Morbidities
  • Among disabled Medicaid patients with HTN:
    • 60% have at least 3 other serious physical conditions (on a billed claim within the past year)
    • 26.7% have a mental health diagnosis
    • 17.6 % have a substance use disorder diagnosis
    • 36.5% have either a mental health or substance use disorder diagnosis
    • 9.8% have both a mental health and a substance use disorder diagnosis
prescription drug abuse
Prescription Drug Abuse
  • 15.1 million Americans admit abusing prescription drugs
  • The number of people who admit abusing controlled prescription drugs increased from 7.8 million in 1992 to 15.1 million in 2003.
  • In 2003, 2.3 million teens between the ages of 12 and 17 (9.3 percent) admitted abusing a prescription drug in the past year; 83 percent of them admitted abusing opioids.
  • In 2002, controlled prescription drugs accounted for 23 percent of all drug-related emergency department mentions in the U.S
  • -- Under the Counter: The Diversion and Abuse of Controlled Prescription Drugs in the U.S. (July 2005); CASA – The National Center on Addiction and Substance Abuse at Columbia University
pain management vs opioid addiction
Pain Management vs Opioid Addiction

You are now entering . . .

Achieve Adequate Pain Control

Prevent Prescription Drug Addiction

. . . the No-Win Zone!

strategies to address at risk substance use and suds in primary care setting
Strategies to Address At-Risk Substance Use and SUDs in Primary Care Setting
  • Screening
  • Brief Intervention
  • Motivational Interviewing
  • Referral
  • Care Management
  • Medication-Assisted Recovery
  • Recovery-Oriented Systems of Care
primary care without a team approach
Primary Care without A Team Approach

Preventive Services = 7.4 hrs / day

Chronic Dz (well-controlled panel) = 3.5 hrs/day

Chronic Dz (poorly-controlled panel) = 10.6 hrs/day

Østbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005 May-Jun;3(3):209-14.

screening in primary care
Screening in Primary Care










Beck Anxiety Inventory

HITS (domestic violence)

Epworth Sleepiness Scale

screening brief intervention in primary care
Screening & Brief Intervention in Primary Care
  • AHRQ Evidence Review does recommend alcohol screening & brief intervention
      • After primary care brief, multi-contact interventions, patients reduced average drinks per week by 13%–34% and increased the proportion drinking at moderate or safe levels by 10%–19% compared with controls.

BUT, . . . the USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use.

Whitlock EP, Green CA, Polen MR, Berg A, Klein J, Siu A, Orleans CT. Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use. Rockville (MD): Agency for Healthcare Research and Quality (US); 2004 Mar.

brief intervention frames
Brief Intervention -- FRAMES
  • Feedback
    • “I am specifically concerned about your substance use because…”
  • Responsibility
    • “What you do with your substance use is up to you.”
  • Advice
    • “In my medical opinion, you can best minimize your health risks by…”
  • Menu
    • “What do you think would work for you if you decided to make a change?”
  • Empathy
    • “It is not easy to change.”
  • Self-Efficacy
    • “I can see that you are a strong person.”
does the mental health sector need more primary care
Does the Mental Health Sector Need More Primary Care?
  • 25-year survival deficit -- Schizophrenia Excess Mortality
    • 28% due to  suicide
    • 12% due to  accidents
    • 60% due to  everything else
  • S Brown. Excess mortality of schizophrenia. A meta-analysis The British Journal of Psychiatry 171: 502-508 (1997)
uncoordinated care when we just don t talk
Uncoordinated Care – When We Just Don’t Talk
  • Jane Doe -- 37 y/o F w/ Bipolar Disorder
    • Lithium (Lithobid®)
    • Aripiprazole (Abilify®)
    • Divalproex Sodium (Depakote®)
  • Jane Doe – 37 y/o fertile female smoker with HTN & two-weeks of productive cough
    • Azithromycin (Zithromax Z-Pack®)
    • ACE + HCTZ (Vaseretic®)
    • OCP’s (Yaz®)
    • Bupropion (Zyban® or Wellbutrin®)
three way integration mental health substance abuse primary care
Three-Way Integration – Mental Health, Substance Abuse, & Primary Care
  • 40 percent of those with an alcohol use disorder also had an independent mood disorder and 60 percent of those with a drug use disorder had an independent mood disorder (Grant, Stinson, Dawson, Chou, Dufour, Compton, et al., 2004).
  • Integrated treatment for both problems is the standard of care for clients with substance abuse and depressive symptoms or any co-occurring mental disorder.
    • TIP 48:Managing Depressive Symptoms in Substance Abuse Clients during Early Recovery. SAMHSA/CSAT Treatment Improvement Protocol Series; 2008.
clinical scenarios
Clinical Scenarios
  • Diabetic patient with depression
  • Insomnia patient using increasing doses of Xanax®
  • CHF patient who self-treats PTSD with alcohol
  • Chronic back pain patient develops opioid addiction
  • Alcohol patient in detox with HTN and chest pain
  • Sickle cell patient with heroin addiction has painful crisis
  • Obese, smoking diabetic worried that he is addicted to the Darvocet® he takes for neuropathic pain.
  • Schizophrenia patientgains 100 lbs and develops diabetes
  • Bipolar patient on lithium has hypothyroidism and high blood pressure
status quo fragmentation
Status Quo = Fragmentation
  • Silos:
    • Public health
    • Medical care
    • Behavioral Health
    • Mental health
    • Substance Abuse
    • Faith Communities
    • Employers
    • Legislators policymakers
    • Payors / Funders
roles for primary care in specialty substance abuse treatment setting
Roles for Primary Care in Specialty Substance Abuse Treatment Setting
  • Screening for Medical Co-Morbidities
  • Treatment of Co-Morbid Medical Conditions
    • Asthma/COPD, Blood Pressure, Diabetes, etc.
  • Coordination / Care Management with Medical Specialty Providers
    • Infectious Disease (HIV-AIDS, Hepatitis C, Tuberculosis)
    • Gastroenterology / Hepatology(Liver Failure, Cirrhosis, Hepatitis)
  • Coordination / Care Management with Mental Health Specialty Providers
can primary care improve sa treatment effectiveness
Can Primary Care Improve SA Treatment Effectiveness?
  • Survey of 2878 patients in 52 treatment programs
    • At 12-month follow-up, patients who attended programs with on-site primary medical care (compared with patients who attended programs with no primary medical care) experienced :
      • Significantly less addiction severity
      • No significant difference in medical severity .
  • Referral to off-site primary care exerted no detectable effects on either addiction severity or medical severity.

Friedmann PD, Zhang Z, Hendrickson J, Stein MD, Gerstein DR. Effect of primary medical care on addiction and medical severity in substance abuse treatment programs. J Gen Intern Med. 2003 Jan;18(1):1-8.

primary care impact on sa treatment
Primary Care Impact on SA Treatment
  • DESIGN: Randomized controlled trial conducted between April 1997 and December 1998.
  • SETTING AND PATIENTS: Adult men and women (n = 592) who were admitted to a large health maintenance organization chemical dependency program in Sacramento, Calif.
  • INTERVENTIONS: Patients were randomly assigned to receive treatment through an integrated model, in which primary health care was included within the addiction treatment program (n = 285), or an independent treatment-as-usual model, in which primary care and substance abuse treatment were provided separately (n = 307). Both programs were group based and lasted 8 weeks, with 10 months of aftercare available.

Weisner C, Mertens J, Parthasarathy S, Moore C, Lu Y. Integrating primary medical care with addiction treatment: a randomized controlled trial. JAMA. 2001 Oct 10;286(14):1715-23.

impact on outcomes
Impact on Outcomes
    • Both groups showed improvement on all drug and alcohol measures.
    • Overall, there were no differences in total abstinence rates between the integrated care and independent care groups (68% vs 63%, P =.18).
    • Patients with SA-related medical conditions (SAMCs) were more likely to be abstinent in the integrated care group than the independent care group(69% vs 55%, P =.006; odds ratio [OR], 1.90)
    • This was true for both those with medical (OR, 3.38) and psychiatric (OR, 2.10) SAMCs.
four quadrant clinical integration model 2010 national council b mauer
Four-Quadrant Clinical Integration Model (~2010) --National Council, B. Mauer

Mental Health / Substance Use Complexity


An Issue Brief on Lessons Learned and Challenges Ahead


coordinated care
Coordinated Care
  • Tracking & Confirmation of Referrals & Follow-up
  • Sharing of Medical Records
  • Sharing of Prescribing Changes & Medication Lists
  • Inter-Operable Electronic Health Records
  • Mutual Participation in Effective Health Information Exchange
collaborative care
Collaborative Care
  • All of the Above plus . . .
  • Team-Based Case Conferences
  • Frequent Interaction on Therapeutic Strategy
  • Patient-Centered, Shared Decision-Making
  • Shared Care Management
  • Joint Decision-Making on Medication Changes
  • Frequent, secure communication by phone, e-mail, & videoconferencing
national collaborations
National Collaborations
baby steps
Baby Steps
  • NIATx / NACHC Collaborative
niatx resource links
NIATx Resource Links

cherokee health systems
Cherokee Health Systems
  • “CHS follows a generalist approach even for behavioral health issues. The PCP has to deal with everyone that walks in the door, and the BHC should be able to as well.”

Integration of Mental Health, Substance Abuse, & Primary Care; AHRQ, 2008.

haight ashbury integrated care
Haight Ashbury Integrated Care

Over 200 paid staff and 500 volunteers provide services at over 15 facilities to over 19,000 clients, with the vast majority served by the substance abuse programs.

“Haight Ashbury’s vision of integrated care follows an “any door is the right door” philosophy. The integrated care clinic on Mission Street provides primary care, substance abuse treatment services, mental health services, and intensive case management (which can include referrals to other organizations for assistance with housing, food, clothing, and employment) within a unified team service delivery model.” -- AHRQ Evidence Report

haight ashbury
Haight Ashbury
  • Lessons Learned:
    • Patients are socially and clinically complex – HIV, homelessness, and addiction commonly co-occur. A team approach is essential.
    • Weekly team meetings include front desk staff since they are the first point of contact and thereby necessarily involved in the triage process.
    • Clients meet initially with a case manager and “are literally walked from office to office” by the case manager as they move through the system.
    • Warm hand-offs have been instrumental in patient adherence with treatment plans.
  • Obstacles to Overcome:
    • Each of the three services, primary care, mental health, and substance abuse treatment, have their own traditional charting cultures and legal requirements. Combining the three into one comprehensive charting system has involved legal counsel along with cultural and process considerations of the three services.
integration allows us to triangulate interventions
Integration Allows us to Triangulate Interventions

Family &Community

Primary Care



Psychologists & Behavioral Health

Systems Change

the power of integration
The Power of Integration

What would happen if all the health professionals came together and created a therapeutic community of healers for whole people?

Faith Communities

Mental Health

Substance Abuse Treatment

Primary Care

community level teamwork a real system of care
Community-Level Teamwork – A Therapeutic CommunityCommunity-Level Teamwork – A Real System of Care

Faith Communities

Mental Health

Substance Abuse Treatment

Behavioral Health


Inpatient Programs

Primary Care

recovery oriented systems of care
Recovery-Oriented Systems of Care
  • No one can whistle a symphony. It takes a whole orchestra to play it.

-- H.E. Luccock

embracing one another soaring together
Embracing One Another, Soaring Together

“We are all as angels, with only one wing;

We can only fly when we embrace each other.

-- Luciano de Crescenzo